Rheumatoid Arthritis in Adults: Management: NICE Guideline Draft For Consultation, January 2018

DRAFT FOR CONSULTATION
1 Rheumatoid arthritis in adults: management

2
3 NICE guideline
4 Draft for consultation, January 2018
5
This guideline covers the diagnosis and management of rheumatoid arthritis in

adults.
Who is it for?
 Healthcare professionals
 Commissioners and providers of services
 People with rheumatoid arthritis, their families and carers.
This guideline will update and replace NICE guideline CG79 (published February
2009).
We have reviewed the evidence and updated or added new recommendations on

investigations following diagnosis, treat-to-target strategy, initial pharmacological
management, symptom control and monitoring. You are invited to comment on the
new and updated recommendations. These are marked as [2018].
You are also invited to comment on recommendations that NICE proposes to delete
from the 2009 guideline.
We have not updated recommendations shaded in grey, and cannot accept

comments on them. In some cases, we have made minor wording changes for
clarification.
See update information for a full explanation of what is being updated.
This version of the guideline contains:
Rheumatoid arthritis: NICE guideline DRAFT (January 2018) 1 of 37

 the draft recommendations

 rationale and impact sections that explain why the committee made the 2018
recommendations and how they might affect practice.
 the guideline context
 recommendations for research.
Information about how the guideline was developed is on the guideline’s page on the
NICE website. This includes the evidence reviews, the scope, and details of the
committee and any declarations of interest.
Full details of the evidence and the committee’s discussion on the 2018
recommendations is in the evidence reviews. Evidence for the 2009
recommendations is in the full version of the 2009 guideline

2 Contents
3
4 Recommendations ..................................................................................................... 4
5 1.1 Referral, diagnosis and investigations........................................................... 4
6 1.2 Treat-to-target strategy ................................................................................. 5
7 1.3 Communication and education ...................................................................... 6
8 1.4 Initial pharmacological management ............................................................. 6
9 1.5 Further pharmacological management .......................................................... 7
10 1.6 Symptom control ........................................................................................... 8
11 1.7 The multidisciplinary team ............................................................................. 9
12 1.8 Non-pharmacological management .............................................................. 9
13 1.9 Monitoring ................................................................................................... 11
14 1.10 Timing and referral for surgery ................................................................. 12
15 Terms used in this guideline ................................................................................. 13
16 Recommendations for research ............................................................................... 14
17 Rationale and impact................................................................................................ 18
18 Investigations following diagnosis ......................................................................... 18
19 Investigations (ultrasound in diagnosis) ................................................................ 19
20 Treat-to-target strategy ......................................................................................... 20
21 DMARDs ............................................................................................................... 21
22 Short-term bridging treatment with glucocorticoids ............................................... 24
23 Symptom control ................................................................................................... 25
24 Monitoring ............................................................................................................. 26
25 Putting this guideline into practice ............................................................................ 27
26 Context ..................................................................................................................... 29
27 More information ................................................................................................... 30
28 Update information ................................................................................................... 31
29 Recommendations that have been deleted or changed........................................ 32
30

2 Recommendations
People have the right to be involved in discussions and make informed
decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show
the strength (or certainty) of our recommendations, and has information about
prescribing medicines (including off-label use), professional guidelines,
standards and laws (including on consent and mental capacity), and
safeguarding.
3 1.1 Referral, diagnosis and investigations
4 Referral from primary care

5 1.1.1 Refer for specialist opinion any adult with suspected synovitis of
6 undetermined cause. Refer urgently (even with a normal acute-phase
7 response or negative rheumatoid factor) if any of the following apply:
8  the small joints of the hands or feet are affected

9  more than one joint is affected
10  there has been a delay of 3 months or longer between onset of
11 symptoms and seeking medical advice. [2009, amended 2018]
12 Investigations
13 These recommendations on investigations are for specialist care.
14 Investigations for diagnosis
15 1.1.2 Offer to carry out a blood test for rheumatoid factor in adults with
16 suspected rheumatoid arthritis (RA) who are found to have synovitis on
17 clinical examination. [2009]
18 1.1.3 Consider measuring anti-cyclic citrullinated peptide (CCP) antibodies in

19 adults with suspected RA if they are negative for rheumatoid factor, and

1 there is a need to inform decision-making about starting combination

2 therapy. [2009, amended 2018]
3 1.1.4 X-ray the hands and feet early in the course of the diseasein adults with
4 suspected RA and persistent synovitisin these joints. [2009, amended
5 2018]
6 Investigations following diagnosis
7 1.1.5 As soon as possible after establishing a diagnosis of RA:
8  measure anti-CCP antibodies, unless already measured to inform

9 diagnosis
10  X-ray the hands and feet to establish whether erosions are present,
11 unless X-rays were performed to inform diagnosis
12  measure functional ability using, for example, the Health Assessment
13 Questionnaire (HAQ), to provide a baseline for assessing the functional
14 response to treatment. [2018]
15 1.1.6 If anti-CCP antibodies are present or there are erosions on X-ray:
16  tell the person that they have an increased risk of radiological

17 progression but not necessarily an increased risk of poor function, and
18  emphasise the importance of monitoring their condition, and seeking
19 rapid access to specialist care if disease worsens or they have a flare.
20 [2018]
To find out why the committee made the [2018] recommendations on

investigations following diagnosis and how they might affect practice, see rationale
and impact.
21 1.2 Treat-to-target strategy

22 1.2.1 Treat active RA in adults with the aim of achieving a target of remission or
23 low disease activity if remission cannot be achieved (treat-to-target).
24 [2018]

1 1.2.2 Consider making the target remission rather than low disease activity for
2 people with an increased risk of radiological progression (presence of
3 anti-CCP antibodies or erosions on X-ray at baselines assessment).
4 [2018]
5 1.2.3 In adults with active RA, measure C-reactive protein (CRP) and disease
6 activity (using a composite score such as DAS28) monthly until the target
7 of remission or low disease activity is achieved. [2018]
To find out why the committee made the [2018] recommendations on treat-to-
target strategy and how they might affect practice, see rationale and impact.
8 1.3 Communication and education

9 1.3.1 Explain the risks and benefits of treatment options to adults with RA in
10 ways that can be easily understood. Throughout the course of their
11 disease, offer them the opportunity to talk about and agree all aspects of
12 their care, and respect the decisions they make. [2009]
13 1.3.2 Offer verbal and written information to adults with RA to:
14  improve their understanding of the condition and its management, and

15  counter any misconceptions they may have. [2009]
16 1.3.3 Adults with RA who wish to know more about their disease and its
17 management should be offered the opportunity to take part in existing
18 educational activities, including self-management programmes. [2009]
19 1.4 Initial pharmacological management
20 Conventional DMARDs
21 1.4.1 For adults with newly diagnosed active RA:
22  Offer first-line treatment with conventional disease-modifying anti-

23 rheumatic drug (cDMARD) monotherapy using oral methotrexate,
24 leflunomide or sulfasalazine as soon as possible and ideally within
25 3 months of onset of persistent symptoms.

1  Consider hydroxychloroquine for first-line treatment as an alternative to

2 oral methotrexate, leflunomide or sulfasalazine for mild or palindromic
3 disease.
4  Escalate dose as tolerated. [2018]
5 1.4.2 Consider short-term bridging treatment with glucocorticoids (oral,

6 intramuscular or intra-articular) when starting a new cDMARD. [2018]
To find out why the committee made the [2018] recommendation on short-term
bridging treatment with glucocorticoids and how they might affect practice, see
rationale and impact.
8 1.4.3 Offer additional cDMARDs (oral methotrexate, leflunomide, sulfasalazine

9 or hydroxychloroquine) in combination in a step-up strategy when the
10 treatment target (remission or low disease activity) has not been achieved
11 despite dose escalation. [2018]
To find out why the committee made the [2018] recommendations on cDMARDs
and how they might affect practice, see rationale and impact.
12
13 1.5 Further pharmacological management
14 Biological and targeted synthetic DMARDs

15 NICE has technology appraisal guidance on biological and targeted synthetic
16 synthetic DMARDs for RA. For full details, see our web page on arthritis.
17 The recommendations below are from NICE technology appraisal guidance 72. The
18 2009 guideline committee reviewed the evidence on anakinra and incorporated the
19 recommendations into the guideline. The technology appraisal was then withdrawn.
20 1.5.1 On the balance of its clinical benefits and cost effectiveness, anakinra is
21 not recommended for the treatment of RA, except in the context of a
22 controlled, long-term clinical study. [2009]

1 1.5.2 Patients currently receiving anakinra for RA may suffer loss of wellbeing if
2 their treatment were discontinued at a time they did not anticipate.
3 Therefore, patients should continue therapy with anakinra until they and
4 their consultant consider it is appropriate to stop. [2009]
5 1.5.3 Do not offer the combination of tumour necrosis factor-α (TNF-α) inhibitor
6 therapy and anakinra for RA. [2009]
7 Glucocorticoids
8 1.5.4 Offer short-term treatment with glucocorticoids for managing flares in
9 adults with recent-onset or established disease to rapidly decrease
10 inflammation. [2009]
11 1.5.5 In adults with established RA, only continue long-term treatment with
12 glucocorticoids when:
13  the long-term complications of glucocorticoid therapy have been fully

14 discussed, and
15  all other treatment options (including biological and targeted synthetic
16 DMARDs) have been offered. [2009]
17 1.6 Symptom control

18 1.6.1 Consider oral non-steroidal anti-inflammatory drugs (NSAIDs, including
19 traditional NSAIDs and cox II selective inhibitors), when control of pain or
20 stiffness is inadequate. Take account of potential gastrointestinal, liver
21 and cardio-renal toxicity, and the person's risk factors, including age and
22 pregnancy. [2018]
23 1.6.2 When treating symptoms of RA with oral NSAIDs:
24  offer the lowest effective dose for the shortest possible time,
25  offer a proton pump inhibitor (PPI), and
26  review risk factors for adverse eventsregularly. [2018]
27 1.6.3 If a person with RA needs to take low-dose aspirin, healthcare

28 professionals should consider other treatments before adding an NSAID

1 (with a PPI) if pain relief is ineffective or insufficient. [2009, amended

2 2018]
To find out why the committee made the [2018] recommendations on symptom
control and how they might affect practice, see rationale and impact.
4 1.7 The multidisciplinary team

5 1.7.1 Adults with RA should have ongoing access to a multidisciplinary team.
6 This should provide the opportunity for periodic assessments (see 1.9.1,
7 1.9.2 and 1.9.3) of the effect of the disease on their lives (such as pain,
8 fatigue, everyday activities, mobility, ability to work or take part in social or
9 leisure activities, quality of life, mood, impact on sexual relationships) and
10 help to manage the condition. [2009]
11 1.7.2 Adults with RA should have access to a named member of the

12 multidisciplinary team (for example, the specialist nurse) who is
13 responsible for coordinating their care. [2009]
14 1.8 Non-pharmacological management
15 Physiotherapy
16 1.8.1 Adults with RA should have access to specialist physiotherapy, with
17 periodic review (see 1.9.1, 1.9.2 and 1.9.3), to:
18  improve general fitness and encourage regular exercise

19  learn exercises for enhancing joint flexibility, muscle strength and
20 managing other functional impairments
21  learn about the short-term pain relief provided by methods such as
22 transcutaneous electrical nerve stimulators [TENS] and wax baths.
23 [2009]

1 Occupational therapy
2 1.8.2 Adults with RA should have access to specialist occupational therapy,
3 with periodic review (see 1.9.1, 1.9.2 and 1.9.3), if they have:
4  difficulties with any of their everyday activities, or

5  problems with hand function. [2009]
6 Hand exercise programmes

7 1.8.3 Consider a tailored strengthening and stretching hand exercise
8 programme for adults with RA with pain and dysfunction of the hands or
9 wrists if:
10  they are not on a drug regimen for RA, or

11  they have been on a stable drug regimen for RA for at least 3 months.
12 [2015]
13 1.8.4 The tailored hand exercise programme for adults with RA should be
14 delivered by a practitioner with training and skills in this area. [2015]
15 Podiatry
16 1.8.5 All adults with RA and foot problems should have access to a podiatrist for
17 assessment and periodic review of their foot health needs (see 1.9.1,
18 1.9.2 and 1.9.3). [2009]
19 1.8.6 Functional insoles and therapeutic footwear should be available for all
20 adults with RA if indicated. [2009]
21 Psychological interventions
22 1.8.7 Offer psychological interventions (for example, relaxation, stress
23 management and cognitive coping skills1) to help adults with RA adjust to
24 living with their condition. [2009]
25 NICE has a guideline on depression in adults with a chronic physical health problem.
1 Such as managing negative thinking.

1 Diet and complementary therapies

2 1.8.8 Inform adults with RA who wish to experiment with their diet that there is
3 no strong evidence that their arthritis will benefit. However, they could be
4 encouraged to follow the principles of a Mediterranean diet (more bread,
5 fruit, vegetables and fish; less meat; and replace butter and cheese with
6 products based on vegetable and plant oils). [2009]
7 1.8.9 Inform adults with RA who wish to try complementary therapies that
8 although some may provide short-term symptomatic benefit, there is little
9 or no evidence for their long-term efficacy. [2009]
10 1.8.10 If an adult with RA decides to try complementary therapies, advise them:
11  these approaches should not replace conventional treatment

12  this should not prejudice the attitudes of members of the
13 multidisciplinary team, or affect the care offered. [2009]
14 1.9 Monitoring
15 1.9.1 Ensure that all adults with RA have:
16  rapid access to specialist care for worsening disease or flares

17  information about when and how to access specialist care, and
18  ongoing drug monitoring. [2018]
19 1.9.2 Consider a review appointment to take place 6 months after achieving

20 treatment target (remission or low disease activity) to ensure that the
21 target has been maintained. [2018]
22 1.9.3 Offer all adults with RA, including those who have achieved the treatment
23 target, an annual review to:
24  assess disease activity and damage, and measure functional ability

25 (using, for example, the Health Assessment Questionnaire [HAQ])
26  check for the development of comorbidities, such as hypertension,
27 ischaemic heart disease, osteoporosis and depression

1  assess symptoms that suggest complications, such as vasculitis and

2 disease of the cervical spine, lung or eyes
3  organise appropriate cross referral within the multidisciplinary team
4  assess the need for referral for surgery (see section 1.10)
5  assess the effect the disease is having on a person's life. [2009,
6 amended 2018]
7 1.9.4 For adults who have maintained the treatment target (remission or low
8 disease activity) for at least 1 year without glucocorticoids, consider
9 cautiously reducing drug doses or stopping drugs in a step-down strategy.
10 Return promptly to the previous DMARD regimen if the treatment target is
11 no longer met. [2018]
12 1.9.5 Do not use ultrasound for routine monitoring of disease activity in adults
13 with RA. [2018]
To find out why the committee made the [2018] recommendations on monitoring
and how they might affect practice, see rationale and impact.
14 1.10 Timing and referral for surgery

15 1.10.1 Offer to refer adults with RA for an early specialist surgical opinion if any
16 of the following do not respond to optimal non-surgical management:
17  persistent pain due to joint damage or other identifiable soft tissue

18 cause
19  worsening joint function
20  progressive deformity
21  persistent localised synovitis. [2009]
22 1.10.2 Offer to refer adults with any of the following complications for a specialist
23 surgical opinion before damage or deformity becomes irreversible:
24  imminent or actual tendon rupture

25  nerve compression (for example, carpal tunnel syndrome)
26  stress fracture. [2009]

1 1.10.3 When surgery is offered to adults with RA, explain that the main2
2 expected benefits are:
3  pain relief,
4  improvement, or prevention of further deterioration, of joint function,
5 and
6  prevention of deformity. [2009]
7 1.10.4 Offer urgent combined medical and surgical management to adults with
8 RA who have suspected or proven septic arthritis (especially in a
9 prosthetic joint). [2009]
10 1.10.5 If an adult with RA develops any symptoms or signs that suggest cervical
11 myelopathy3:
12  request an urgent MRI scan, and

13  refer for a specialist surgical opinion. [2009]
14 1.10.6 Do not let concerns about the long-term durability of prosthetic joints
15 influence decisions to offer joint replacements to younger adults with RA.
16 [2009]
17 Terms used in this guideline
18 Bridging treatment
19 Glucocorticoids used for a short period of time when a person is starting a new
20 DMARD, intended to improve symptoms while waiting for the new DMARD to take
21 effect (which can take 2 to 3 months).
22 Conventional disease-modifying anti-rheumatic drug (cDMARD)

23 Conventional disease-modifying anti-rheumatic drugs are synthetic drugs that modify
24 disease rather than just alleviating symptoms. They include methotrexate,
25 sulfasalazine, leflunomide and hydroxychloroquine, but do not include biological
26 DMARDs and targeted synthetic DMARDs.
2 Cosmetic improvements should not be the dominant concern.

3 For example, paraesthesia, weakness, unsteadiness, reduced power, extensor plantars.

1 Palindromic
2 Palindromic rheumatism is an inflammatory arthritis that causes attacks of joint pain
3 and swelling similar to RA. Between attacks the joints return to normal.
4 Rapid access to specialist care

5 Direct access to specialist care without the need of a GP referral.
6 Step-up strategy
7 Additional DMARDs are added to DMARD monotherapy when disease is not
8 adequately controlled.
9 Step-down strategy
10 During treatment with 2 or more DMARDs, tapering and stopping at least 1 drug
11 once disease is adequately controlled.
12 Synovitis
13 Soft tissue joint swelling.
14 Treat-to-target
15 A treat-to-target strategy is a strategy that defines a treatment target (such as
16 remission or low disease activity) and applies tight control (for example, monthly
17 visits and respective treatment adjustment) to reach this target. The treatment
18 strategy often follows a protocol for treatment adaptations depending on the disease
19 activity level and degree of response to treatment.
20 Recommendations for research

21 The guideline committee has made the following high-priority recommendations for
22 research.
23 1 Analgesics
24 What is the clinical and cost effectiveness of analgesic drugs other than non-
25 steroidal anti-inflammatory drugs (NSAIDs) in adults with rheumatoid arthritis (RA)
26 whose pain or stiffness control is not adequate?

1 Why this is important

2 Analgesics (including NSAIDs, paracetamol, opioids and compound analgesics) are
3 sometimes used with disease-modifying treatments to relieve pain and stiffness
4 when symptom control is inadequate. Current practice regarding the choice of
5 analgesic in RA is variable. The evidence is limited for many of the analgesic drugs
6 other than NSAIDs, and their relative effectiveness is unknown. Further research in
7 this area may inform future guidance on the use of analgesic drugs other than
8 NSAIDs for controlling symptoms.
9 2 Short-term bridging treatment with glucocorticoids

10 What is the clinical and cost effectiveness of short-term bridging treatment with
11 glucocorticoids for adults with RA starting a new disease-modifying anti-rheumatic
12 drug (DMARD), including the most effective dosing strategy and mode of
13 administration?

15 All DMARDs have a slow onset of action. In some cases, response may not be seen
16 for 2 to 3 months. In contrast, glucocorticoids have an immediate effect on joint pain
17 and swelling. In clinical practice, several different regimens are prescribed to ‘bridge’
18 the time between the initial prescription of DMARDs and the clinical response.
19 However, good quality evidence from randomised controlled trials (RCTs)
20 demonstrating the effectiveness of glucocorticoids as bridging treatment is limited
21 and inconclusive. Further research is needed to inform recommendations for practice
22 regarding whether bridging treatment with steroids should be used until the new
23 DMARD begins to take effect.
24 The optimal dosing strategy and mode of administration for bridging glucocorticoids
25 also needs to be established. Although the anti-inflammatory response is dose
26 dependent, side effects of glucocorticoids vary according to both the dose and the
27 duration of treatment.
28 3 Ultrasound in monitoring
29 What is the clinical and cost effectiveness of using ultrasound to monitor disease in
30 adults with RA when clinical examination is inconclusive or inconsistent with other
31 signs of disease activity?


2 RA is a chronic inflammatory condition that needs regular review to enable
3 adjustments in management to achieve a target of remission or low disease activity.
4 Although ultrasound is able to show subclinical inflammation or erosions in some

5 people in clinical remission, evidence from RCTs does not support using ultrasound
6 for routine monitoring. However, ultrasound may be useful for assessing disease
7 activity in some people with RA; specifically, when clinical examination is
8 inconclusive or is inconsistent with other signs of disease activity (for example, pain
9 or markers of inflammation). There is no reliable evidence on the added value of
10 ultrasound as part of a monitoring strategy in these subgroups.
11 In addition, when there is inconsistency between clinical examination and disease

12 activity, it may be unclear if the person has subclinical inflammatory synovitis or
13 more of a widespread pain syndrome, which is not inflammatory. These need very
14 different treatments, so it is important to define them accurately.
15 4 Ultrasound in diagnosis
16 What is the clinical and cost effectiveness of using ultrasound in addition to clinical
17 assessment when there is uncertainty about the diagnosis in adults with suspected
18 RA?

2 Early diagnosis of RA is essential to reduce the impact of the disease on multiple

3 systems in the body. The course of RA and the initial presentation can be highly
4 variable; most people with RA have definite synovitis on clinical assessment, but
5 sometimes this is not obvious, leading to uncertainty about the diagnosis. Ultrasound
6 is a non-invasive and relatively inexpensive imaging modality that can detect
7 subclinical synovitis and early erosive disease. It might help determine an early
8 diagnosis of RA when the diagnosis would otherwise be uncertain. Early diagnosis
9 enables earlier treatment providing an opportunity to improve the longer term
10 outcomes for people with RA. The use of ultrasound may also allow healthcare
11 professionals to be more confident about ruling out a diagnosis of RA.
12 5 Management of poor prognosis

13 What is the clinical and cost effectiveness of managing RA with a poor prognosis
14 (identified as presence of anti-CCP antibodies or evidence of erosions on X-ray at
15 diagnosis) with a different strategy from that used for standard management of RA?

17 Current recommendations suggest all people with RA should be offered the same
18 management; however clinical experience suggests that the condition responds less
19 well in some people and some suffer progressive radiographic damage and impaired
20 function despite standard management. Several factors have been identified in the
21 literature that, if present and identified early in the course of the disease, may predict
22 a poor prognosis (greater radiographic progression). These include anti-CCP
23 antibody positivity and the presence of radiographic erosions at baseline. At present
24 it is unclear whether people with poor prognostic markers should have different
25 management early in the disease, and whether this would improve radiographic and
26 functional (HAQ) outcomes in this group.
27 6 Subcutaneous methotrexate
28 What is the clinical and cost effectiveness of subcutaneous methotrexate compared
29 with oral methotrexate for adults with early onset RA starting a new DMARD?


2 Methotrexate is an important drug in the treatment of RA. Subcutaneous
3 administration is an alternative option for people who have side effects with oral
4 treatment. Evidence on the effectiveness of subcutaneous methotrexate is lacking,
5 but its effects may be superior, due to increased bioavailability, and side effects
6 fewer than with oral drugs. Research on subcutaneous methotrexate will inform
7 future guideline recommendations.
8 Rationale and impact
9 Investigations following diagnosis
10 Why the committee made recommendations 1.1.5 and 1.1.6

11 Evidence showed that anti-cyclic citrullinated peptide (CCP) antibodies and
12 radiographic damage at baseline were both important prognostic factors for
13 subsequent radiographic progression. Anti-CCP antibodies are usually measured
14 and X-rays often taken as part of diagnosis. When this has not been done, the
15 committee agreed that the tests should be performed as soon as possible. The
16 results will inform discussions with the patient about how their rheumatoid arthritis
17 (RA) might progress and reinforce the importance of active monitoring and rapidly
18 seeking specialist care if the disease worsens.
19 There was limited evidence on poor function, as measured by the Health

20 Assessment Questionnaire (HAQ), as a prognostic factor. However, the committee
21 agreed that functional ability (measured, for example, by HAQ) should be determined
22 at diagnosis to provide a baseline for assessing response to treatment at the annual
23 review.
24 Evidence suggests that all people with RA should be offered the same management
25 strategy; however, in the committee’s experience some people may respond less
26 well and have more progressive radiographic damage and impaired function.
27 Because the evidence was limited as to whether people with poor prognostic
28 markers should follow a different management strategy to improve radiographic and
29 functional (HAQ) outcomes, the committee agreed to make a research
30 recommendation.

1 How the recommendations might affect practice

2 Anti-CCP antibodies are usually measured so there should be no change in current
3 practice. X-raying the hands and feet and measuring functional ability at baseline
4 reflects current best practice, but not everyone with RA currently has these
5 investigations. There may be an increase in the number of X-rays, especially in units
6 without early inflammatory arthritis clinics, but this is unlikely to have a substantial
7 resource impact.
8 Measuring functional ability at baseline will involve a change of practice for some
9 providers, but the cost is low and so it this is not expected to have a substantial
10 resource impact.
11 Full details of the evidence and the committee’s discussion are in evidence review B:
12 Risk factors.
13 Investigations (ultrasound in diagnosis)
14 Why the committee made the research recommendation on ultrasound in

15 diagnosis
16 Ultrasound is not used widely in diagnosing RA, but use is increasing and depends
17 on the clinic and the rheumatologist. Evidence was inconsistent and too limited for
18 the committee to make any recommendation for or against its use in diagnosis. The
19 committee noted that the studies generally included only people with clinically
20 definite synovitis and agreed that ultrasound may be more useful when there is
21 uncertainty about the diagnosis after clinical assessment. They decided to make a
22 research recommendation to inform future guidance on who (if anyone) should have
23 ultrasound to aid diagnosis.
24 Full details of the evidence and the committee’s discussion are in evidence review A:
25 Ultrasound for diagnosis.

1 Treat-to-target strategy
2 Why the committee made recommendations 1.2.1 to 1.2.3
3 Strategy and treatment target

4 Evidence showed that a treat-to-target strategy was more effective than usual care
5 for managing RA and improved outcomes at no additional cost. The committee
6 agreed that this approach was more likely to achieve rapid and sustained disease
7 control .
8 No evidence was identified to indicate whether a target of remission or low disease

9 activity was more effective. However, the committee agreed that remission (for
10 example, a DAS28 score of less than 2.6) is the most appropriate target for most
11 people, but for some who are unable to achieve remission despite a treat-to-target
12 approach with appropriate escalation, low disease activity (for example, a DAS28
13 score of less than 3.2) is acceptable. It was agreed that for those identified as being
14 at risk of poor prognosis, a target of remission may be more appropriate.
15 Frequency of monitoring for active disease

16 No studies were identified that compared different frequencies of monitoring
17 specifically in people with active disease. The committee noted that the 2009
18 guideline recommended monthly monitoring and that this was used in some of the
19 studies of a treat-to-target strategy. The committee agreed that monthly monitoring
20 of C-reactive protein (CRP) and disease activity was most appropriate for active
21 disease. This allows dose escalation of disease-modifying anti-rheumatic drugs
22 (DMARDs), checking the need for short-term bridging treatment with glucocorticoids
23 and whether people are tolerating the drug regimen, assessing side effects,
24 providing support and encouraging adherence.
25 People at risk of poor outcomes

26 There was no evidence that people with a poor prognosis should have different
27 management in terms of the treatment target or the frequency of monitoring.
28 However, in the committee’s experience RA often responds less well to standard
29 management in this group. The committee agreed that the recommendations on
30 treat-to-target with monthly monitoring should ensure that people with a poor

1 prognosis receive effective treatment, but they decided to make a research

2 recommendation to inform future guidance for managing RA in this group.

4 A treat-to-target strategy is current best practice in most NHS settings. The 2016
5 National Clinical Audit for Rheumatoid Arthritis and Early Inflammatory Arthritis
6 indicated that healthcare professionals set a treatment target for about 90% of their
7 patients. Although the 2018 recommendation specifies a target of remission or low
8 disease activity, rather than a disease level previously agreed with the person, the
9 committee agreed that these are the targets commonly used and so this is unlikely to
10 involve a significant change in practice.
11 Monthly monitoring was recommended in the 2009 guideline, but the committee
12 acknowledged that many clinics do not monitor active disease this often. A regional
13 survey (Tugnet 2013) reported that about two-thirds of people with RA received
14 monthly CRP monitoring but only a quarter had monthly monitoring of disease
15 activity (with about 40% in dedicated early arthritis clinics) until disease control was
16 achieved. The committee were unsure whether these rates reflected practice across
17 England and noted that practice had improved since the survey was conducted in
18 2011. However, the committee agreed that monthly monitoring would likely involve a
19 change in practice in some clinics.
20 Full details of the evidence and the committee’s discussion are in evidence review C:
21 Treat-to target.
22 DMARDs
23 Why the committee made recommendations 1.4.1, and 1.4.3
24 First-line treatment
25 Evidence showed that starting treatment with more than 1 conventional DMARD
26 (cDMARD) was no more effective than starting with a single cDMARD. The
27 committee agreed that cDMARD monotherapy might have fewer side effects and
28 recommended cDMARD monotherapy as first-line treatment. This differed from the
29 2009 guideline which recommended combination therapy. The difference is largely a

1 result of inclusion of different evidence and a different approach to analysing that

2 evidence.
3 Many of the studies included in the 2009 guideline used cDMARDs that are no
4 longer commonly used in UK practice (for example, ciclosporin), and these studies
5 were excluded from the evidence for the 2018 update. In addition, the 2018 update
6 included new evidence published after the 2009 guideline. Further, a different
7 approach to analysing the evidence was taken, with the 2018 update aiming to
8 identify the most effective cDMARD strategy (monotherapy, sequential monotherapy,
9 step-up therapy, step-down therapy or parallel combination therapy) as well as which
10 cDMARD should be used. The 2009 guideline compared treatment strategies only,
11 regardless of the particular cDMARDs, and combined evidence according to
12 treatment strategy.
13 The evidence included in the 2018 update was therefore different to that included in
14 2009 and supported cDMARD monotherapy as first-line treatment.
15 Evidence from randomised controlled trials in people who had never had a DMARD
16 showed no consistent differences in the effectiveness of methotrexate, leflunomide
17 and sulfasalazine as monotherapies. The drugs also had similar costs. The
18 committee agreed that any of these drugs can be used as first-line treatment.
19 Hydroxychloroquine was less effective, but fewer people stopped treatment because
20 of side effects. The committee agreed that hydroxychloroquine could be considered
21 for people with mild or palindromic disease.
22 People at risk of poor outcomes

23 Evidence for different first-line treatment in people with a poor prognosis was limited
24 so the committee decided not to make a separate recommendation for this group.
25 They agreed that the recommendation for dose increases and treating to target (with
26 the aim of keeping disease activity low) should ensure adequate treatment for these
27 people. Given the limited evidence in this area, the committee also decided that the
28 possible benefit of managing RA with a poor prognosis with a different strategy was
29 a priority for future research.

1 Further treatment
2 Evidence supported adding another cDMARD when needed (step-up strategy) rather
3 than replacing the cDMARD with another (sequential monotherapy). The committee
4 acknowledged that more side effects were possible with a step-up strategy, but in
5 their experience these could be managed by drug monitoring and were outweighed
6 by the clinical benefit of combination treatment when monotherapy was inadequate.
7 A published cost analysis supported a step-up approach rather than sequential
8 monotherapy.
9 Subcutaneous methotrexate
10 No evidence was found for subcutaneous methotrexate, but the committee agreed
11 that the effects may be superior and side effects fewer than with oral cDMARDs.
12 However, because subcutaneous methotrexate is significantly more expensive than
13 other cDMARD options, the committee was not able to recommend this without
14 evidence of clinical benefit and cost effectiveness relative to oral cDMARDs. The
15 committee decided to make a research recommendation to inform future guidance.

17 The 2009 guideline recommended a combination of cDMARDs (including
18 methotrexate and at least 1 other cDMARD) for newly diagnosed RA and
19 emphasised the importance of starting effective cDMARD therapy as soon as
20 possible.
21 The 2009 recommendation to start with combination therapy was not widely adopted.
22 The 2016 National Clinical Audit for Rheumatoid Arthritis and Early Inflammatory
23 Arthritis reported that only 46% of people with RA received combination cDMARDs
24 at any time. Currently there is variation in practice regarding the choice of
25 cDMARD(s) and treatment strategy, with many healthcare professionals preferring to
26 start with monotherapy and only use combination therapy when response is
27 inadequate.
28 The 2018 recommendations to start with monotherapy and add drugs when the
29 response is inadequate are unlikely to have a substantial impact on practice or
30 resources, as they align with the current approach taken by many healthcare
31 professionals. However, the recommendations should result in a more consistent

1 treatment strategy and reduce the number of people prescribed combination therapy
2 on diagnosis.
3 The 2009 guideline recommended methotrexate as one of the first drugs used in
4 combination therapy. The 2018 recommendations do not specify which cDMARD
5 should be used at any stage of treatment. Again, this will be unlikely to have a
6 significant impact on practice, and methotrexate is likely to remain one of the most
7 commonly prescribed drugs.
8 The recommendations on dose escalation and reduction have not changed

9 substantially from the 2009 guideline and reflect current clinical practice. The
10 committee clarified that dose reduction and the use of a step-down strategy should
11 only be considered after a person has maintained the treatment target for at least
12 1 year without the use of glucocorticoids.
13 Full details of the evidence and the committee’s discussion are in evidence review F:
14 DMARDs.
15 Short-term bridging treatment with glucocorticoids
16 Why the committee made recommendation 1.4.3

17 Evidence from randomised controlled trials on the use of short-term bridging
18 treatment with glucocorticoids to relieve symptoms while people are waiting for a
19 new DMARD to take effect was limited. There was some evidence that fewer people
20 withdrew from the studies due to inefficacy or adverse events when they were taking
21 glucocorticoids, although there was no evidence that glucocorticoids were effective
22 in terms of disease activity score, quality of life or function, as studies did not report
23 these outcomes. In the committee’s experience people with active arthritis may
24 benefit from the anti-inflammatory effects of glucocorticoids. However, for others with
25 less active disease this additional treatment may not be needed. The committee
26 agreed that short-term glucocorticoids could be considered on a case-by-case basis.
27 Because of the lack of good quality evidence, the committee decided to make a
28 research recommendation to determine the effectiveness of short-term
29 glucocorticoids for adults taking a new DMARD, including the most effective
30 regimen.


2 Most healthcare professionals offer short-term bridging treatment with
3 glucocorticoids to adults starting a new DMARD. They can continue to offer this but
4 the recommendation encourages them to consider whether this additional treatment
5 is always needed. Therefore this is unlikely to result in additional spending for the
6 NHS.
7 Full details of the evidence and the committee’s discussion are in evidence review H:
8 Glucocorticoids.
9 Symptom control
10 Why the committee made recommendations 1.6.1 and 1.6.2

11 Evidence suggested that non-steroidal anti-inflammatory drugs (NSAIDs) may offer a
12 small benefit in relieving symptoms for adults with RA (including pain and stiffness).
13 The committee agreed that this was likely to outweigh the increase in gastrointestinal
14 adverse events associated with NSAIDs. To minimise adverse events, the committee
15 agreed that NSAIDs should be used at the lowest doses and for the shortest
16 possible time, with a proton pump inhibitor, and that risk factors for adverse events
17 should be reviewed regularly. The recommendations for analgesic treatment in this
18 guideline replace those in the 2009 guideline.
19 There was limited evidence on paracetamol, opioids and tricyclic antidepressants

20 and no evidence for nefopam, gabapentinoids or selective serotonin reuptake
21 inhibitor (SSRI) and SSNRI antidepressants. The committee acknowledged that the
22 2009 guideline had recommended analgesics other than NSAIDs for pain control.
23 However, the 2009 guideline indicated that the evidence on analgesia other than
24 NSAIDs was ’sparse’. No further evidence on these drugs was identified since the
25 publication of the 2009 guideline. The committee for the 2018 guideline decided to
26 make a research recommendation rather than a practice recommendation on non-
27 NSAID analgesics.

29 Current practice regarding the choice of analgesic is variable, with paracetamol,
30 compound analgesics and NSAIDs all commonly used to control symptoms. Choice

1 of analgesic tends to be based on individual effectiveness as well as the person’s

2 risk profile, tolerance, and side effects. In particular, there are some groups of people
3 for whom NSAIDs are unsuitable because of contraindications, comorbidities or
4 tolerability, and other people who are currently benefiting from analgesic drugs other
5 than NSAIDs. The current approach is likely to continue but there may be an
6 increase in prescribing of NSAIDs instead of other analgesic drugs for people with
7 newly diagnosed RA.
8 Full details of the evidence and the committee’s discussion are in evidence review G:
9 Analgesics.
10 Monitoring
11 Why the committee made recommendations 1.9.1, 1.9.2, 1.9.4 and 1.9.5
12 Frequency of monitoring when treatment target has been achieved

13 No evidence was identified on monitoring frequency once the treatment target has
14 been achieved. However, the committee agreed that once people with RA had
15 achieved the treatment target, and this was sustained at a 6-month follow-up
16 appointment, there was no need for additional routine appointments to be scheduled
17 other than the annual reivew. All people with RA should have an annual review.
18 In people with established RA (RA for at least 2 years), the evidence suggested that
19 patient-initiated rapid access and scheduled medical review every 3 to 6 months
20 were similarly effective. The committee agreed that all adults with RA should have
21 rapid access to specialist care for worsening disease or disease flares, and ongoing
22 drug monitoring.
23 Ultrasound in monitoring
24 Randomised controlled evidence did not support using ultrasound for routine
25 monitoring of RA. However, in the committee’s experience ultrasound can be useful
26 for monitoring when clinical examination is inconclusive or is inconsistent with other
27 signs of disease activity (for example, pain or markers of inflammation). The
28 committee decided to make a research recommendation to inform future guidance
29 about using ultrasound in these situations.


2 The frequency of monitoring and review appointments for people who have reached
3 the treatment target vary around the country, with some people being seen more
4 often than needed and others not receiving adequate follow-up. The 2018
5 recommendations are likely to reduce unwarranted variation.
6 Most people with RA currently have rapid access to specialist care when they have a
7 flare. The 2016 National Clinical Audit for Rheumatoid Arthritis and Early
8 Inflammatory Arthritis reported that 92% of people had access to urgent advice, with
9 97% of providers running a telephone advice line. Therefore the recommendation will
10 not affect current practice.
11 Use and availability of ultrasound varies widely across the country and even between
12 healthcare professionals in the same department. Some healthcare professionals
13 use it routinely whereas others use it on a case-by-case basis. The recommendation
14 should reduce the overall use of ultrasound while still allowing its use for selected
15 subgroups.
16 Full details of the evidence and the committee’s discussion are in evidence review E:
17 Frequency of monitoring.
18 Putting this guideline into practice

19 [This section will be finalised after consultation]
20 NICE has produced tools and resources [link to tools and resources tab] to help you
21 put this guideline into practice.
22 [Optional paragraph if issues raised] Some issues were highlighted that might need
23 specific thought when implementing the recommendations. These were raised during
24 the development of this guideline. They are:
25  [add any issues specific to guideline here]

26  [Use 'Bullet left 1 last' style for the final item in this list.]

1 Putting recommendations into practice can take time. How long may vary from
2 guideline to guideline, and depends on how much change in practice or services is
3 needed. Implementing change is most effective when aligned with local priorities.
4 [Clinical topics only] Changes recommended for clinical practice that can be done
5 quickly – like changes in prescribing practice – should be shared quickly. This is
6 because healthcare professionals should use guidelines to guide their work – as is
7 required by professional regulating bodies such as the General Medical and Nursing
8 and Midwifery Councils.
9 Changes should be implemented as soon as possible, unless there is a good reason

10 for not doing so (for example, if it would be better value for money if a package of
11 recommendations were all implemented at once).
12 Different organisations may need different approaches to implementation, depending

13 on their size and function. Sometimes individual practitioners may be able to respond
14 to recommendations to improve their practice more quickly than large organisations.
15 Here are some pointers to help organisations put NICE guidelines into practice:
16 1. Raise awareness through routine communication channels, such as email or

17 newsletters, regular meetings, internal staff briefings and other communications with
18 all relevant partner organisations. Identify things staff can include in their own
19 practice straight away.
20 2. Identify a lead with an interest in the topic to champion the guideline and motivate
21 others to support its use and make service changes, and to find out any significant
22 issues locally.
23 3. Carry out a baseline assessment against the recommendations to find out

24 whether there are gaps in current service provision.
25 4. Think about what data you need to measure improvement and plan how you
26 will collect it. You may want to work with other health and social care organisations
27 and specialist groups to compare current practice with the recommendations. This
28 may also help identify local issues that will slow or prevent implementation.

1 5. Develop an action plan, with the steps needed to put the guideline into practice,
2 and make sure it is ready as soon as possible. Big, complex changes may take
3 longer to implement, but some may be quick and easy to do. An action plan will help
4 in both cases.
5 6. For very big changes include milestones and a business case, which will set out
6 additional costs, savings and possible areas for disinvestment. A small project group
7 could develop the action plan. The group might include the guideline champion, a
8 senior organisational sponsor, staff involved in the associated services, finance and
9 information professionals.
10 7. Implement the action plan with oversight from the lead and the project group.
11 Big projects may also need project management support.
12 8. Review and monitor how well the guideline is being implemented through the
13 project group. Share progress with those involved in making improvements, as well
14 as relevant boards and local partners.
15 NICE provides a comprehensive programme of support and resources to maximise

16 uptake and use of evidence and guidance. See our into practice pages for more
17 information.
18 Also see Leng G, Moore V, Abraham S, editors (2014) Achieving high quality care –
19 practical experience from NICE. Chichester: Wiley.
20 Context
21 Rheumatoid arthritis (RA) is an inflammatory disease largely affecting synovial joints.
22 It typically affects the small joints of the hands and the feet, and usually both sides
23 equally and symmetrically, although any synovial joint can be affected. It is a
24 systemic disease and so can affect the whole body, including the heart, lungs and
25 eyes.
26 The incidence of the condition is low, with around 1.5 men and 3.6 women
27 developing RA per 10,000 people per year. The overall occurrence of RA is 2 to 4
28 times greater in women than men. The peak age of incidence in the UK for both
29 genders is the 70s, but people of all ages can develop the disease.

1 Drug management aims to relieve symptoms, as pain relief is the priority for people
2 with RA, and to modify the disease process. Disease modification slows or stops
3 radiological progression, which is closely correlated with progressive functional
4 impairment.
5 RA can result in a wide range of complications for people with the disease, their
6 carers, the NHS and society in general. The economic impact of this disease
7 includes:
8  direct costs to the NHS and associated healthcare support services

9 •indirect costs to the economy, including the effects of early mortality and lost
10 productivity
11  the personal impact of RA and subsequent complications for people with RA and
12 their families.
13 Approximately one-third of people stop work because of the disease within 2 years of
14 onset, and this increases thereafter. Clearly this disease is costly to the UK economy
15 and to individuals.
16 More information
[The following sentence is for post-consultation versions only – editor to update
hyperlink with guideline number]You can also see this guideline in the NICE
pathway on [pathway title]. [Note: this should link to the specific topic pathway, not
to the overarching one.]
To find out what NICE has said on topics related to this guideline, see our web
page on [developer to add and link topic page title or titles; editors can advise if
needed].
[The following sentence is for post-consultation versions only – editor to update

hyperlink with guideline number]
For full details of the evidence and the committee’s discussions, see the evidence
reviews. [link to evidence tab]You can also find information about how the
guideline was developed, [link to documents tab] including details of the

committee.
2 Update information
3 This guideline is an update of NICE guideline 79 (published February 2009) and will
4 replace it.
5 New recommendations have been added on investigations following diagnosis, treat-

6 to-target strategy, initial pharmacological management, symptom control and
7 monitoring.
8 Recommendations are marked as [2018] if the recommendation is new or the

9 evidence has been reviewed.
10 NICE proposes to delete some recommendations from the 2009 guideline, because
11 either the evidence has been reviewed and the recommendations have been
12 updated, or NICE has updated other relevant guidance and has replaced the original
13 recommendations. Recommendations that have been deleted or changed sets out
14 these recommendations and includes details of replacement recommendations.
15 Where there is no replacement recommendation, an explanation for the proposed
16 deletion is given.
17 Where recommendations are shaded in grey and end [2009], the evidence has not
18 been reviewed since the original guideline.
19 Where recommendations are shaded in grey and end [2009, amended 2018], the
20 evidence has not been reviewed but changes have been made to the
21 recommendation. These may be:
22  changes to the meaning of the recommendation (for example, because of

23 equalities duties or a change in the availability of medicines, or incorporated
24 guidance has been updated)
25  editorial changes to the original wording to clarify the action to be taken.

1 These changes are marked with yellow shading, and explanations of the reasons for
2 the changes are given in ‘Recommendations that have been deleted or changed’ for
3 information.
4 See also the original NICE guideline and supporting documents.
5 Recommendations that have been deleted or changed
6 Recommendations to be deleted
Recommendation in 2009 guideline Comment
In people with recent-onset active RA, Replaced by: Treat active RA in adults
measure CRP and key components of with the aim of achieving a target of
disease activity (using a composite score remission or low disease activity (1.2.1)
such as DAS28) monthly until
treatment has controlled the disease to a
level previously agreed with the
person with RA. [2009] (1.5.1.2)
Measure CRP and key components of Replaced by: In adults with active RA,
disease activity (using a composite score measure C-reactive protein (CRP) and
such as DAS28) regularly in people with disease activity (using a composite score
RA to inform decision-making about: such as DAS28) monthly until the target
- increasing treatment to control of remission or low disease activity is
disease achieved. (1.2.2)
- cautiously decreasing treatment
when disease is controlled. [2009]
(1.5.1.1)

In people with newly diagnosed active Replaced by:

RA, offer a combination of DMARDs For adults with newly diagnosed active
(including methotrexate) and at least one RA:
other DMARD, plus short-term
- Offer first-line treatment with
glugogorticoids) as first-line treatment as
conventional disease-modifying
soon as possible, ideally within 3 months
anti-rheumatic drug (cDMARD)
of the onset of persistent symptoms
monotherapy using oral
(1.4.1.1)
methotrexate, leflunomide or
sulfasalazine as soon as possible
In people with newly diagnosed RA for and ideally within 3 months of
whom combination DMARD therapy is onset of persistent symptoms.
not appropriate[2], start DMARD - Escalate dose as tolerated
monotherapy, placing greater emphasis (1.4.1)
on fast escalation to a clinically effective
dose rather than on the choice of
DMARD. (1.4.1.4) For adults with newly diagnosed mild or
palindromic disease, consider
hydroxychloroquine for first-line treatment
as an alternative to monotherapy with
oral methotrexate, leflunomide or
sulfasalazine (1.4.2)
Offer additional cDMARDs (oral

methotrexate, leflunomide, sulfasalazine
or hydroxychloroquine) in combination in
a step-up strategy when the treatment
target (remission or low disease activity)
has not been achieved despite dose
escalation. (1.4.4)
Consider offering short-term treatment Replaced by: Consider short-term
with glucocorticoids (oral, bridging treatment with glucocorticoids
intramuscular or intra-articular) to rapidly (oral, intramuscular or intra-articular)
improve symptoms in people with when starting a new cDMARD. (1.4.3)
newly diagnosed RA if they are not
already receiving glucocorticoids as part
of DMARD combination therapy. (1.4.1.2)
In people with recent-onset RA receiving Replaced by: For adults who have
combination DMARD therapy and in maintained the treatment target
whom sustained and satisfactory levels (remission or low disease activity) for at
of disease control have been achieved, least 1 year without glucocorticoids,
consider cautiously reducing drug doses
cautiously try to reduce drug doses to
or stopping drugs in a step-down
levels that still maintain disease control.
strategy. Return promptly to the previous
(1.4.1.3) DMARD regimen if the treatment target is
no longer met. (1.10.7)
In people with established RA whose
disease is stable, cautiously reduce
dosages of disease-modifying or
biological drugs. Return promptly to
disease-controlling dosages at the first
sign of a flare. (1.4.1.5)

When introducing new drugs to improve

disease control into the treatment
regimen of a person with established RA,
consider decreasing or stopping their
pre-existing rheumatological drugs once
the disease is controlled. (1.4.1.6)
In any person with established Replaced by:
rheumatoid arthritis in whom disease- Ensure that all adults with RA have:
modifying or biological drug doses are
- rapid access to specialist care for
being decreased or stopped,
worsening disease or flares
arrangements should be in place for
prompt review. (1.4.1.7) - information about when and how
to access specialist care, and
- ongoing drug monitoring. (1.9.1)
Consider a review appointment to take

place 6 months after achieving treatment
target (remission or low disease activity)
to ensure that the target has been
maintained. (1.9.2)
Offer analgesics (for example, Replaced by: Consider oral non-steroidal
paracetamol, codeine or compound anti-inflammatory drugs (NSAIDs),
analgesics) to people with RA whose including cox II selective inhibitors, when
pain control is not adequate, to control of pain or stiffness is inadequate.
potentially reduce their Take account of potential
need for long-term treatment with non- gastrointestinal, liver and cardio-renal
steroidal anti-inflammatory drugs toxicity, and the person's risk factors,
including age. (1.6.1)
(NSAIDs) or cyclo-oxygenase-2 (COX-2)
inhibitors. (1.4.4.1)
All oral NSAIDs/COX-2 inhibitors have

analgesic effects of a similar magnitude
but vary in their potential gastrointestinal,
liver and cardio-renal toxicity;
therefore, when choosing the agent and
dose, healthcare professionals should
take into account individual patient risk
factors, including age. When prescribing
these drugs, consideration should be
given to appropriate assessment and/or
ongoing monitoring of these risk factors.
(1.4.4.4)
Oral NSAIDs/COX-2 inhibitors should be Replaced by: When treating symptoms of
used at the lowest effective dose for RA with oral NSAIDs:
the shortest possible period of time. - offer the lowest effective dose for
(1.4.4.2) the shortest possible time, and
- review risk factors and the need
When offering treatment with an oral for gastroprotective treatment
NSAID/COX-2 inhibitor, the first choice regularly. (1.6.2)
should be either a standard NSAID or a

COX-2 inhibitor. In either case, these

should be co-prescribed with a proton
pump inhibitor (PPI), choosing the one
with the lowest acquisition cost. (1.4.4.3)
If NSAIDs or COX-2 inhibitors are not Deleted as new recommendations to
providing satisfactory symptom control, follow a ‘treat-to-target’ strategy mean
review the disease-modifying or that this should apply throughout
biological drug regimen. (1.4.4.6) management when symptom control is
not adequate and therefore this specific
recommendation is no longer required.
Offer people with satisfactorily controlled Replaced by: Ensure that all adults with
established RA review appointments RA have:
at a frequency and location suitable to - rapid access to specialist care for
their needs. In addition, make sure they: worsening disease or flares
- have access to additional visits - information about when and how
for disease flares, to access specialist care, and
- know when and how to get rapid - ongoing drug monitoring. (1.9.1)
access to specialist care, and
- have ongoing drug monitoring.
(1.5.1.3)
In people with recent-onset active RA, Replaced by:
measure CRP and key components of Treat active RA in adults with the aim of
disease activity (using a composite score achieving a target of remission or low
such as DAS28) monthly until disease activity (treat-to-target). (1.2.1)
treatment has controlled the disease to a
level previously agreed with the In adults with active RA, measure C-
person with RA. [2009] (1.5.1.2) reactive protein (CRP) and disease
activity (using a composite score such as
DAS28) monthly until the target of
remission or low disease activity is
achieved. (1.2.2)
1
2 Amended recommendation wording (change to meaning)

Recommendation in 2009 Recommendation in Reason for change
guideline current guideline
Refer for specialist opinion Refer for specialist opinion Recommendations
any person with suspected any adult with suspected 1.1.1.1 and 1.1.1.2
persistent synovitis of synovitis of undetermined from 2009 have been
undetermined cause. Refer cause. Refer urgently (even merged to clarify the
urgently if any of the with a normal acute-phase intension and reduce
following apply: response or negative any ambiguity
- the small joints of the rheumatoid factor) if any of regarding when to
hands or feet are the following apply: refer urgently.
affected - the small joints of the
- more than one joint is hands or feet are affected
affected
- more than one joint is
- there has been a delay
affected
of 3 months or longer
between onset of - there has been a delay of

symptoms and seeking 3 months or longer

medical advice. between onset of
(1.1.1.1) symptoms and seeking
medical advice. (1.1.1)
Refer urgently any person
with suspected persistent
synovitis of undetermined
cause, even if their blood
tests show a normal acute-
phase response or negative
rheumatoid factor. (1.1.1.2)
Consider measuring anti- Consider measuring anti- Combination therapy
cyclic citrullinated peptide cyclic citrullinated peptide is no longer
(CCP) antibodies in people (CCP) antibodies in adults recommended as the
with suspected RA if: with suspected RA if they are first line treatement
- they are negative for negative for rheumatoid option, therefore this
rheumatoid factor, and factor. (1.1.3) recommendation has
been edited for
- there is a need to inform
consistency with the
decision-making about
updated DMARD
starting combination
recommendations.
therapy. (1.1.2.2)
X-ray the hands and feet X-ray the hands and feet in This now falls under
early in the course of the adults with suspected RA a sub-heading of
disease in people with and persistent synovitis. ‘investigations for
persistent synovitis in these (1.1.4) diagnosis’. It has
joints. (1.1.2.3) been updated to
clarify that this
applies to adults with
suspected RA as
there is a separate
recommendation for
those with diagnosed
RA.
If a person with RA needs to If a person with RA needs to Edited to reflect that
take low-dose aspirin, take low-dose aspirin, aspirin is no longer
healthcare professionals healthcare professionals used as an
should consider other should consider other analgesic, and non-
analgesics before treatments before adding an NSAID analgesics
substituting or adding an NSAID (with a PPI) if pain are no longer
NSAID or COX-2 inhibitor relief is ineffective or recommended within
(with a PPI) if pain relief is insufficient. (1.6.3) the guidance,
ineffective or insufficient. therefore other
(1.4.4.5) treatments for RA
should be
considered instead
of NSAIDs.
Offer people with RA an Offer all adults with RA, Edited to clarify that
annual review to: including those who have this applies to all
- assess disease activity achieved the treatment adults with RA, even
and damage, and target, an annual review to: if they have reached
measure functional - assess disease activity their treatment
ability (using, for and damage, and target.
example, the Health measure functional ability

Assessment (using, for example, the

Questionnaire [HAQ]) Health Assessment
- check for the Questionnaire [HAQ])
development of - check for the
comorbidities, such as development of
hypertension, ischaemic comorbidities, such as
heart disease, hypertension, ischaemic
osteoporosis and heart disease,
depression osteoporosis and
- assess symptoms that depression
suggest complications, - assess symptoms that
such as vasculitis and suggest complications,
disease of the cervical such as vasculitis and
spine, lung or eyes disease of the cervical
- organise appropriate spine, lung or eyes
cross referral within the - organise appropriate
multidisciplinary team cross referral within the
- assess the need for multidisciplinary team
referral for surgery (see - assess the need for
section 1.6) referral for surgery (see
- assess the effect the section 1.10)
disease is having on a - assess the effect the
person's life. (1.5.1.4) disease is having on a
person's life. (1.9.3)
1
2 ISBN:

Rheumatoid Arthritis in Adults: Management: NICE Guideline Draft For Consultation, January 2018

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Rheumatoid Arthritis in Adults: Management: NICE Guideline Draft For Consultation, January 2018

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DRAFT FOR CONSULTATION

1 Rheumatoid arthritis in adults: management

This guideline covers the diagnosis and management of rheumatoid arthritis in

We have reviewed the evidence and updated or added new recommendations on

We have not updated recommendations shaded in grey, and cannot accept

See update information for a full explanation of what is being updated.

This version of the guideline contains:

Rheumatoid arthritis: NICE guideline DRAFT (January 2018) 1 of 37

 the draft recommendations

Rheumatoid arthritis: NICE guideline DRAFT (January 2018) 2 of 37

Rheumatoid arthritis: NICE guideline DRAFT (January 2018) 3 of 37

3 1.1 Referral, diagnosis and investigations

4 Referral from primary care

8  the small joints of the hands or feet are affected

14 Investigations for diagnosis

18 1.1.3 Consider measuring anti-cyclic citrullinated peptide (CCP) antibodies in

Rheumatoid arthritis: NICE guideline DRAFT (January 2018) 4 of 37

1 there is a need to inform decision-making about starting combination

6 Investigations following diagnosis

7 1.1.5 As soon as possible after establishing a diagnosis of RA:

8  measure anti-CCP antibodies, unless already measured to inform

15 1.1.6 If anti-CCP antibodies are present or there are erosions on X-ray:

16  tell the person that they have an increased risk of radiological

To find out why the committee made the [2018] recommendations on

21 1.2 Treat-to-target strategy

Rheumatoid arthritis: NICE guideline DRAFT (January 2018) 5 of 37

8 1.3 Communication and education

13 1.3.2 Offer verbal and written information to adults with RA to:

14  improve their understanding of the condition and its management, and

19 1.4 Initial pharmacological management

22  Offer first-line treatment with conventional disease-modifying anti-

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1  Consider hydroxychloroquine for first-line treatment as an alternative to

5 1.4.2 Consider short-term bridging treatment with glucocorticoids (oral,

8 1.4.3 Offer additional cDMARDs (oral methotrexate, leflunomide, sulfasalazine

13 1.5 Further pharmacological management

14 Biological and targeted synthetic DMARDs

Rheumatoid arthritis: NICE guideline DRAFT (January 2018) 7 of 37

13  the long-term complications of glucocorticoid therapy have been fully

17 1.6 Symptom control

23 1.6.2 When treating symptoms of RA with oral NSAIDs:

27 1.6.3 If a person with RA needs to take low-dose aspirin, healthcare

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1 (with a PPI) if pain relief is ineffective or insufficient. [2009, amended

4 1.7 The multidisciplinary team

11 1.7.2 Adults with RA should have access to a named member of the

14 1.8 Non-pharmacological management

18  improve general fitness and encourage regular exercise

Rheumatoid arthritis: NICE guideline DRAFT (January 2018) 9 of 37

4  difficulties with any of their everyday activities, or

6 Hand exercise programmes

10  they are not on a drug regimen for RA, or

1 Such as managing negative thinking.

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1 Diet and complementary therapies

10 1.8.10 If an adult with RA decides to try complementary therapies, advise them:

11  these approaches should not replace conventional treatment

16  rapid access to specialist care for worsening disease or flares

19 1.9.2 Consider a review appointment to take place 6 months after achieving

24  assess disease activity and damage, and measure functional ability

Rheumatoid arthritis: NICE guideline DRAFT (January 2018) 11 of 37

1  assess symptoms that suggest complications, such as vasculitis and

14 1.10 Timing and referral for surgery